Preoperative Anxiety

Ilan Keidan MDPediatric Anesthesia

Anesthesia and Intensive CareSheba Medical Center

Children with high anxiety levels will have more :

1.Complications during induction- breath holding , laryngospasm, desaturation.

2. Intraoperative anesthetics requirements. 3. Postoperative pain 4. Increased post operative analgesic 5.Symptoms of emergence delirium on awakening

from anesthesia. 6.Trouble falling asleep after surgery.7.higher rate of new-onset behavioral problems at

1 week after surgery.

Postoperative behavioral changes in children after surgery.

Treatment of preoperative anxiety in children

• Medications - Midazolam

• Preoperative programs for children and parents.

• PPIA –Parental presence during Induction of Anesthesia

• Distraction – games, video, music. Limiting the number of medical personnel interacting with the child

Midazolam Pros and Cons(The King is Naked?)

Pros

Mostly studied drug

No Brainer

Effective

Predictable

Safe

Multiple routs of administration

Cons

Kids do not like it

Paradoxical response

and agitation

Can prolong recovery

Increase the respiratory depression effects of narcotics

Clowns as Treatment for Preoperative Anxiety in Children: A Randomized Controlled Trial

Pediatric Anesthesia

Anesthesia and Intensive Care

Sheba Medical Center

Introduction

Anesthesiologists continue to search for an easy and comprehensive method for anxiety reduction in the pediatric surgical population.

We propose that specially trained professional clowns may allay preoperative anxiety and result in a smooth anesthetic induction.

Material and Methods

• The primary end-point of this study was the anxiety manifested by children during the induction of anesthesia.

• Group 1 children did not receive midazolam or clown presence;

• Group 2 children received 0.5 mg/kg oral midazolam 30 minutes before surgery up to a maximum of 15 mg

• Group 3 children had two specially trained clowns present upon arrival to the preoperative holding area and throughout operating room (OR) entrance and mask application for inhalation induction of anesthesia.

Material and Methods• The clown intervention and distraction techniques were semi-

structured; they began in the holding area and lasted for approximately 20-30 minutes. All variation in session length was due to OR timing constraints. The clowns used various methods for entertaining the child according to the child’s age (e.g., magic tricks, gags, music, games, puppets, word games, bubbles, etc) The clowns then accompanied each child into the OR and stayed until the anesthetic induction was complete.

• Each child was videotaped at three different locations: the preoperative holding area, entrance to the OR, and during application of the anesthesia mask. Videos were edited into three separate two minute clips, coded, and then randomly presented to the evaluators.

• All children in the study were videotaped in the holding area until the induction of anesthesia. These blinded evaluators then used the videotapes to rate children’s anxiety for this study. The same evaluator ranked the child’s anxiety at the various time points.

m YPAS

An observational instrument, quantifies children’s anxiety in the preoperative area and during the induction of anesthesia. The instrument distributes 27 items into 5 categories that suggest preoperative anxiety in children: activity, emotional expressivity, state of arousal, vocalization, and use of parents.

Results

• The average age was 4.5 years (range 3-8 years).

• 3 groups were similar with regard to age, sex, type of surgery, and parental anxiety state and trait.

Results

• The clown group had a statistically significant lower m-YPAS score in the preoperative holding area compared to the control group (28.7 ± 4.6 versus 38 ± 12 , p = 0.002 ), and the midazolam group (35.7 ± 11.8, p = 0.04).

• The clowns effect on anxiety reduction continued when the children entered the OR (m-YPAS 37.3 ± 12.3 vs. 50.0 ± 17.4 in the control group, p = 0.005), but equal at this point to the midazolam group (m-YPAS 42.0 ± 10.6, p = 0.7).

• Upon application of the anesthesia mask no significant differences were detected between the groups (62.7 ± 14.6 vs. 49.9 ± 16.0 and 54.4 ± 21.6, p = 0.5) (Table 1).

Results

• In all groups there was a trend towards elevation of anxiety levels from preoperative holding area to OR entry and to application of the anesthesia face mask.

• However, at application of the mask, the clown group had the largest increase in m-YPAS score, which surpassed other groups’ m-YPAS scores (graph 1).

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m-YPAS

Control

Midazolam

Clowns

Holding Area Entrance to OR Mask Induction20

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m-YPAS

Control

Midazolam

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Holding Area Entrance to OR Mask Induction

Changes in children’s perioperative anxiety (modified Yale Preoperative Anxiety Scale; m-YPAS) for the different groups.

Discussion

• This study shows that the presence of trained clowns significantly reduces the preoperative anxiety in children while waiting for anesthesia and surgery.

• Trained clowns clinically and statistically outperform oral midazolam towards this end.

• Unfortunately, once the anesthetic mask is applied to their face, the level of anxiety in the children accompanied by clowns peaks and is greater than the anxiety found in children receiving either oral midazolam or no intervention.

• These data seem to indicate that such an intervention should be either limited to the preoperative period, or that further training is required before this modality can be used in the OR.

Preoperative anxiety the “individual approach”

• “The one size fits all” does not work• Pediatric surgery and anesthesia is a family occasion-

every child and his family need to be evaluated individually.

• Pediatric surgery and anesthesia requires a team effort . Starting with the stuff responsible to explain the NPO guidelines and preventing prolonged starvation to the nurses in the preop the nurses in the OR and the anesthesia team.

• The measures to reduce anxiety requires the attention of both the nurses in the preoperative

• Kids with OSAS should not get midazolam?• We should do more PPIA and distraction